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9812-093 (PLBG)cfl� I— N Cn 04 W O M W � tY C) Z r CD h� W W F- a rn Z co LO N ON U_ °) 0_ Z `rHcc 0 XW LL 0 J Q mVU n M 1:T Z_ co=)r` 0 a J LICENSED CONTRACTOR DECLARATION Thereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date Date Signature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: (,K) I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business & Professionals Code). ( ) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals 'Code). () I am exempt under Section , B&P.C. for, this reason Daie 7 fig 1 Wit' Signature of Ownert�°10 .� ' WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ( ) I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ( ) I have and will maintain workers' compensation insurance, Wrequired by Section 3700 of the Labor Code, for the performance of the work .for which this permit is issued. My workers' compensation insurance carrier & policy no. are: Carver Policy No. (This section need not be completed if the permit valuation is for $100.00 or less). (k) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor C,ode I shall forthwith comply with those Prov'sions e Date: i� - x>�Applicanto ��f-� •� Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees.. IMPORTANT Application is hereby made to the Director of Building and Safety, for a permit subject to the conditions and restrictions set forth on hi" application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. J, 2. Any permit issued as a result of this application becomes null and void.if"7 work is not commenced within 180 days from date of issuance of,such�` permit, or cessation of work for 180 days will subject permit to cancel lation.a.... I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. Date Signature (Owner/Agent BUILDING PERMIT PERMIT# ��-�� DATE VALUATION LOT TRACT i?l�al/9�3 $1.00.00 JOB SITE ADDRESS 49-0855 �i��ON S��.R'�:fiX ASH.IN APN 646-1:0-011 OWNER CONTRACTOR/DESIGNER/ENGINEER CLCIBERT S FU fONT C?NMIA / B L,DER 49'095 `V,ASHINGFON M1 LA QUiNCA CA. 92-253 USE OF PERMIT PLUMBING ACA:NDON.F-SaSTYNG UNDERGROUND OAS 1,1•1114 AND :RMPL CC OV'MEAD YJI' LTJAT[0N PLUTv16B NGFFE $Jt4t00 + r -91,41-TOTAL CONSITWMION AND PIAIN CHECK $1900 / .t.ii";SS P iiELb••.PAID .{ a..LS $t`,,��!t "IY'CD'3tAL PERMIT PUN DUE NOW $18100 i RECEIPT DATE BYE` DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final BLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Neater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: A- 0 F r�9wS 78-495 CALLE TAMPICO — LA QUINTA, CALIFORNIA 92253 ' TELEPHONE -(760) 777-7012 FAX (760) 777-7011 OWNER/BUILDER INFORMATION Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your'protectionyou should be aware that as "Owner/ you are the responsible party of record on such a permit. Building permits are not required robe signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect, yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the City ore County. They are also required by law to put their license number on all permits .for which they apply. If you plan to do your own work, with the exception of various trades that -you plan to subcontract, you should be ' aware of the following information for your benefit and protection: If you employ or otheiwwise engage any persons other than' our immediate family, and the work (including, materials and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer.; If you -are an employer, you must register with the State and Federal Government as an employer and you -are subject to several obligations including State -and Federal income tax withholding, federal, social security taxes, worker's compensation insurance, disability insurance costs and unemployment compensation contributions,. There may be'financial risks for you if you do notearry'out these obligations, and these risks are especially serious with respect to worker's compensation insurance'.. For more specific information about your obligationsunder,Federal Law contact the Iniernal Revenue Service (and, if you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State Law, contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale, property owners.who are not licensed contractors, are allowed to perform their work personally or through. their own employees, without a licensed contractor or, subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing. to be contractors is to secure an "Owner/ Builder" building permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing 'their: own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your community or at 1020 N. Street, Sacramento, California 95814. Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of these matters. The building permit,will not be issued until the verification is returned. Very truly yours, - CITY OF LA QUINTA DEPT. OF BUILDING AND SAFETY 78-495 Calle Tampico La Quintal CA 92253 (760) 777-7012 F 7 ) 777- .0 WNER'S SIGNATURE/ DATE. PROPERTY ADDRESS /0 z -oR3 PERMIT NUMBER(s)